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How To Reduce Foster Care

Without Endangering Children

(Originally published May 2023)

Foster children in the U.S. have several characteristics that increase the difficulty of safely reducing foster care:

Almost half of children placed in foster care due to abuse or neglect are 0-5 at entry into care and almost one-fifth of entries into care are infants.
Young children in foster care often have chronic health problems and disabilities; these infants are exceptionally vulnerable. Approximately 45% of children who die from child maltreatment are infants.
Parents of foster children are poor, often extremely poor. A 2009 survey of parents with open child welfare cases in Washington State found that almost three-fifths of parents with a child in foster care had an annual income under $10,000 and one-fifth of parents with children living in the home or placed out of the home had no income from either welfare or work and were not living with an intimate partner whose annual income was more than $20,000. Many families with open child welfare cases care live on the verge of homelessness, and (at best) have inadequate and unstable housing.
In addition to extreme poverty, most parents with a preschool child in foster care struggle with substance abuse and/or chronic mental illness, and often domestic violence as well. The assertion that many children in foster care have been placed solely due to the poverty related neglect of parents is false. Among parents of young children in foster care, the “big three” of substance abuse, mental illness (often mood disorders) and domestic violence occur in various combinations with poverty, often extreme poverty.
A large percentage of children in foster care have been neglected and physically abused and/or sexually abused as well. Multitype child maltreatment always includes emotional abuse or neglect. The idea that most severe harm resulting from child maltreatment is physical harm is untrue and ignores decades of research on adverse childhood experiences which affect physical and mental health over the life span.

In addition, CPS programs across the country are increasingly staffed by inexperienced caseworkers who know little or nothing about a wide range of subjects important in child protection, including risk assessment, child development, attachment, chronic neglect and chronic multitype maltreatment, not to mention the “big three.”

When young children in danger are not placed in foster care or unlicensed kinship care, caseworkers must depend on in-home safety plans that are difficult to implement and often unreliable. DCYF managers have acknowledged in Child Fatality Reviews (available on-line) that CPS lacks an agency protocol to prevent fentanyl ingestion by young children, and safety plans frequently fail to prevent “roll over” suffocation deaths of infants when parents are struggling with substance abuse.

Nationally, in-home safety planning is arguably the weakest part of child protection practice. It is remarkable that child welfare agencies committed to safe foster care reductions have not made large investments in improving in-home safety plans, but they have not, and neither has the federal Children’s Bureau. In addition, there is little recent research regarding in-home safety planning, which leaves child welfare practitioners dependent on dubious practice wisdom. Furthermore, conscientious implementation of in-home safety plans requires frequent contact with families which is next to impossible when offices are understaffed or have a high vacancy rate.

Finally, in most states child welfare agencies have limited poverty related services to assist low-income families, and what concrete assistance is available is usually ‘one time only’ or for a few months at most. This is a formidable set of obstacles (to put it mildly) to safe foster care reductions involving children, 0-5, especially infants and toddlers in poor health or who have disabilities.

Promising programs and practices in Washington State

Fortunately, Washington has several promising programs and practices, and a long history of innovative practices that has never been taken to scale:

The Parent Child Advocate Program (PCAP) which provides concrete and emotional support to substance abusing women and their child, beginning in the prenatal period and continuing for three years.
Safe Baby Courts (SBC) and Family Treatment Drug Courts (FTDC) offered on a voluntary basis to parents with a legally dependent infant (SBC) or an older child (FTDC) in which a team of professionals meets with parents regularly in a juvenile court setting to support reunification through timely feedback to parents and through an enhanced array of services.
Pregnant and Parenting Women (PPW) residential treatment programs in which mothers retain physical custody of their infant in a protected setting.
Housing support programs - the Washington State legislature recently appropriated about $9 million dollars to fund DCYF’s part in a collaboration with the state’s public housing authorities and non-profit housing organizations which have preliminarily committed 2,076 housing vouchers and apartments for families and youth with open child welfare cases. These housing resources are valued at $63 million dollars for the biennium. This ambitious housing initiative has three purposes: a) prevent foster care, b) reduce the length of foster care or c) prevent homelessness for youth aging out of foster care or detention. The $9 million dollars in state funding will allow DCYF to provide support services to eligible families and youth.
Family Connections program which utilizes foster parents to support and coach parents seeking reunification.
Crisis nurseries, e.g., Vanessa Behan in Spokane, and respite care for low-income families.

What is missing in this list of promising family support programs is a systematic approach to early intervention before an infant is at risk of imminent harm and hopefully before an initial CPS report. The lives of infants in families with combinations of poverty, substance abuse, chronic mental illness and/or domestic violence cannot be effectively protected if outreach to families only occurs when a child is in danger. CPS intervention in these circumstances is often too little, too late, if it occurs at all.

Strengthening public health services to deliver early intervention

Enlightened public policy should not depend solely on CPS reports and interventions for the following child populations:

Infants exposed prenatally to dangerous drugs or alcohol
Infants of parents receiving publicly funded substance abuse or mental health treatment
Infants of parents with a pattern (not one incident) of domestic violence during the past year
Children of any age in families experiencing homelessness

For these child populations, the public policy guideline should be: “a CPS intervention should never be the first or only outreach to parents and their children.” To this end, public health nursing services need to be strengthened around the state, including rural areas, and state law should mandate outreach and an offer of voluntary services to parents and children with four main goals:

To help with basic needs, including housing
To reduce parents’ child-care burden and to assure that children in poor health or with disabilities receive essential services and medical attention
To support a parent’s involvement in substance abuse, mental health or DV services
To make a CPS report when a child is being maltreated, or is clearly in danger due to substance abuse, parental mental illness, or family violence.

The idea that families with multiple high-risk factors should be left alone by all public agencies until a child is at risk of imminent harm is a formula for increasing preventable child deaths.

The widespread view of parent advocates that mandated reporters and CPS programs consistently overreact to information regarding parental substance abuse and mental illness is not supported by evidence. A recent study of 760,863 children born in Washington State between 2006-13 found that of infants diagnosed with prenatal substance exposure (PSE) “less than half (42.2%) … were reported to CPS by hospitals within the neonatal period.” And “few of the infants with diagnosed with PSE were removed into out-of-home care during the neonatal period (13.3%).” (Rebbe, et al, 2019)

Reports of PSE by hospitals and subsequent child removals were highest for infants exposed to amphetamines and cocaine and lowest for infants exposed to cannabis or alcohol.

Regarding racial/ethnic differences in rates of reports and child removals: “Prevalence of PSE births varied by race with 8.1% of Native Americans, 2.8% of black, 1.9% of white and 0.8% of Hispanic births diagnosed with PSE.” The average rate of PSE for all races/ethnicities was 2.1%.

The authors state that “Native American children had a three-fold greater prevalence of opioid PSE than the next two racial categories of white and black, and a five-fold greater pre-valence of amphetamine PSE than the next highest category (white).” When type of substance exposure was held constant in the regression model, “infants with Native American mothers were had higher odds for both reports (OR:1.24) and removals (1.46) to infants with white mothers. No other substance exposure type or maternal race category was found to be statistically significant.” Nevertheless, the authors assert that “in our model with race interacting with substance, we found few statistically significant differences … we found that minority PSE infants are not reported to CPS more than white infants.”

The authors are concerned about the missed opportunities for targeted prevention efforts, including education regarding the dangers of PSE and specialized treatment for pregnant mothers, “all preferable responses to CPS involvement.” And “…our study raise questions about the services that are being offered and provided to families whose newborns are diagnosed with PSE if removals are not occurring.” The likely answer is that these families are receiving few, if any, services prior to a CPS report. This is bad public policy likely to increase all-cause child mortality.

Competent CPS assessment is essential

Prevention, early intervention, and in-home family support services following a CPS report are vitally important in safely reducing entry into foster care rates, but they are not a substitute for competent CPS assessment of risk and safety. Child protection is an essential child welfare function that places a premium on experience. It requires skills that are difficult to acquire and cannot be reduced to checklists or to procedural guidelines.

CPS assessment occurs in an interpersonal milieu in which caseworkers are developing relationships with parents and children, relationships affected by both role definitions and personal feelings regarding family members. No one comes to child protection with an ability to see troubled families as they are without being influenced by emotional reactions to family members. Inexperienced caseworkers strongly motivated to support parents in a recovery process often minimize or deny indications that parents are using substances or endangering children in various ways. On the other hand, when caseworkers take an intense dislike to a parent, they may disregard the parents strengths and exaggerate risks or safety threats. In addition, parents with chronically relapsing conditions such as substance abuse or depression have many ups and downs. Inexperienced caseworkers are likely to give more weight to the impression a parent makes in a couple of home visits than to a lengthy history of CPS reports and treatment failures contained in a case record. Troubled families rarely have a fixed level of capacity to parent; children who seem safe one day can be in danger a few days later due to relapse, an incident of DV or family crisis. Defining risk of imminent harm as “the child is in danger at this moment” endangers the lives of young children.

DCYF Child Fatality Reviews

The difficulty of accurately assessing and working with families who have longstanding substance abuse and mental health issues (and extensive CPS histories) is reflected in DCYF Child Fatality Reviews. The quality of assessment and family engagement described in these reviews varies from exemplary to distressing and in a few cases to appalling and infuriating. Some of the latter group of cases indicate how deficient CPS practice can directly contribute to a child’s death, e.g., the death of B.M, a two-year-old child who died from septic shock and pneumonia on April 21, 2022.

At the time of death, B.M. had unexplained marks and bruising, cuts, burns to a finger and on his bottom, and he was severely malnourished and dehydrated. His weight was 17 lbs., a loss of 4 pounds in the couple of months before his death. “According to the doctor, B.M.’s bottom had a large open wound that appeared to be extremely painful. The doctor explained this wound could be caused by sitting in urine and diarrhea-soaked diapers for hours on end.” He also had initial signs of bed sores. The doctor explained that the death process had begun for the child 36 hours before he died, yet the mother did not seek medical attention.

The fatality review states that from 2012 to March 2022 DCYF received 26 intakes on B.M. and five siblings, 10 of which were screened out and none were founded. There were multiple reports of physical abuse as well as neglect. Eight of the intakes directly referenced B.M. who, along with his siblings, was placed in foster care and made legally dependent soon after his birth. The mother had unexplained mental health problems, and there was a lengthy history of domestic violence between the mother and the children’s fathers.

The dependency on B.M. was dismissed in June 2021 despite multiple reports made recently by the childcare provider about bruising on B.M while in the mother’s care. The mother stopped sending B.M. to childcare during the fall of 2021. According to the fatality review:

“Between August 2021 and B.M.’s death. … DCYF missed opportunities to facilitate a meeting with medical providers, childcare providers … parents and program managers to communicate and collaborate on B.M.’s health even though in December 2021 B.M.’s weight was at the second percentile. This child was starved to the point of death while there was an open CPS case and while CPS caseworkers made home visits. Caseworkers later stated they did not notice the child’s dramatic weight loss because he was in a highchair during their visits!

The fatality review team commented that inexperienced caseworkers had a limited ability to interpret medical records and had received little or no formal training on attachment, child development or malnutrition.

In this extreme case of chronic multitype maltreatment that included systematic denial of food and water, chronic physical abuse and pervasive neglect, three caseworkers failed to recognize multiple indicators of maltreatment for ten months and did not obtain urgently needed medical care for B.M. or medical consultation to inform their decisions. Furthermore, their supervisors did nothing to correct this malpractice. The fatality review team refers to “DCYF’s possible bias as to the mother’s parental capabilities.”

No CPS unit that functions with an apparent lack of concern for a vulnerable child’s health and safety could ever effectively protect children. Inexperience of caseworkers and staffing shortages contributed to B.M.’s death, and so did the lack of recognition of chronic multitype maltreatment by supervisors, along with inadequate training and emotional enmeshment of caseworkers with a mentally ill parent.

It is impossible to make safe foster care reductions when:

Caseworkers assess for severity of harm while ignoring histories of chronic neglect and chronic multitype maltreatment.
Caseworkers are uninterested in the cumulative developmental harm of child maltreatment or in child health and well-being.
Parent and child advocates and courts misrepresent chronic neglect as “just poverty” and have no understanding of the dynamics of chronic maltreatment.
Caseworkers have received little or no training re child development, indicators of malnutrition, attachment, mental illness, or child torture.
Caseworkers are not self-reflective re the effects of their personal feelings about parents and children on their assessments and decision making. ©

References

Child Fatality Review, B.M. (2022), Washington State Department of Children, Youth and Families, Olympia, Washington, available online. www.dcyf.wa.gov/sites/default/files/ecfr-bm22.pdf

Culver, N., “Maddie’s Place to open care facility for drug-addicted newborns at former Vanessa Behan building,”, The Spokesman Review, March 11, 2021

Hildebrandt, U., Graham, C. & Grant, T., “Predictors and moderators of improved social-emotional functioning in mothers with substance abuse disorders and their young children enrolled in a relationship-based community program” (2020). Infant Mental Health Journal, vol. 41, issue 5, pp. 677-696.

Marcenko, M., Lyons, S. & Courtney, M., “Mother’s experiences, resources and needs: The context for reunification.” (March 2011), Children and Youth Services Review, 33 (3), pp. 431-438.

Mirra, M., “Preliminary Commitments of Housing Resources to the Housing & Child Welfare Collaboration between the Washington State Department of Children, Youth and families and Public Housing Authorities and Nonprofit Housing Organizations.” Contact michaelmirratacoma@outlook.com for information.

“Pierce County had the first baby court in the state. Now it’s starting elsewhere,” Amara, April 12, 2021, available online.

Rebbe, R., Mienko, J., Brown, E. & Rowhani-Rahbar, A., “Child protection reports and removals of infants diagnosed with prenatal substance exposure” (2019). Child Abuse & Neglect, 88, pp. 28-36.

Ryder-Marks, M. “2023 Session Was ‘the year of housing’

for Washington Legislature, The Columbian, April 25, 2023.

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©Dee Wilson

deewilson13@aol.com